Critical Realistic Psychiatry & Other Allied Health Disciplines

The fragmented conceptual models that constitute much of psychopathological theory–and that inform related discourse about psychiatric disorders–, seem to prescribe a bounded solution set to a ‘problem’ that the very discourse itself, produces. In characterizing these problems in such a categorical way–steeped in assumptions about the existence of binaries across and within the domains to which a said problem “belongs”–we do little to help ourselves by failing to see the more fundamental biophysical-phenomenological mechanisms of co-emergence that may be in play at every level of analysis. When taken holistically, these may more accurately constitute such ‘problem states’. This is roughly the point that ‘integrated medicine’ as a specialty seeks to address. However, even integrated or functional medicine practitioners still embolden an orientation toward epistemology that is maladaptive when they are keen to reify the legitimacy of their own orientations, at the definitive exclusion of all other approaches, and without scientific or theoretical justification to back such assertions. The fundamental nature of our suffering seems anything but clear; however, a tradition of explanatory reductionism (wherever you look in healthcare, be that your mainstream “western medicine”, your “integrative medicine”, your “natural medicine” etc.)  appears to have normalized a clinical discourse that creates this illusion of explanatory depth: we mistakenly believe that professionals understand, with certainty, a complex mechanism of action by which some structures and processes result in eventual disease . Many people today–practitioners, clients, and the broader public–uncritically accept and conflate these explanatory, pathological ‘maps’ with their ‘territories’. Many seem happy to believe in the sentiment that somebody–some entity–understands the nature of their problems; and by association, the nature of their “solutions”.

In order to get a sense of whether or not this sentiment is based in reality, it may be helpful to take a look at some patterns that we are seeing in practice. With respect to matters of the mind, we see treatment inefficacy, perpetuation of disease & disorder, certain kinds of injustices and other harms, attrition and barriers to engagement, power imbalances, risk deflection, blame, rising costs, etc. To be clear, we think that this reflects a significant failure. Moreover, we feel that the failure is a responsibility of all of us. We also do not intend to imply that the scientific knowledge and psychophysiological tools that have been developed thus far are useless; these technologies are deeply valued and utilized by some people in some situations. However, there has been appalling stagnation in this space–particularly with respect to disorders marked by chronic cognitive disorganization, perceptual anomalies, altered states of consciousness, the inability to selectively attend to sensory information, psychosis, etc–since the 60s!!! (. In addition to this alarming stagnation, a fundamental part of the problem relates to the socio-structural features of healthcare: the stifling, overwrought, inflexible ecology that we call ‘the mental health system’ renders clients unable to easily access those potentially useful technologies that do exist, in an autonomous, self-dignified way. This system design, we argue, just reinforces paternalism, blame, and organizational risk deflection (as opposed to autonomy, symmetrical risk sharing, and inter-relational collaboration, respectively). The failure of the institutional practice of psychiatry and the allied health professions (and really healthcare writ large) warrants immediate attention and action from all stakeholders involved. **We focus here on the failure of the practice as opposed to theoretical or explanatory endeavors because we a) are skeptical of the feasibility of establishing causal models for such dynamic disorders b) find this body of knowledge to only be of value insofar as it has implications for methods/technologies that could be developed in order to ultimately be applied in practice (hopefully effectively).

       It is also important to reflect upon the way (the methods or techniques) in which we represent and discuss information in medicine (and all of science). The language and other signaling that we use, implicitly reflects our judgments about, and epistemic orientations toward, the theories to which we subscribe. Much of ‘psychiatry’ as we know it, seems flawed not only in practice, but in many of the conceptual assumptions (and ways of thinking or not thinking about these assumptions) upon which it is inspired.

When we buy into theoretical frameworks with an epistemic attitude of certainty and arrogance, it is likely that we cause more harm than if we were to subscribe to those same theoretical frameworks with an epistemic attitude of ambiguity and openness. In the latter scheme, we essentially mostly think that a conceptual assumption, claim, or principle is a reasonable prior, but we hold this view with a constant awareness of its potential fallibility . We’re not married to our ideas. We’re always open and always ready to prioritize or de-prioritize these ideas in lock-step with incoming information.  As “professionals”, when we believe that consumer stakeholders are of “lower epistemic status, perhaps we will “consult” (i.e. feign interest in their opinions, while rarely actually listening). In most cases they alone get the last word. They have most decision making power: from problem formulation, to ‘treatment’ practices, to research scope and design, to policy decisions, etc. This inherently undermines progress. It is these very paternalistic, asymmetrical epistemic attitudes that perpetuate the relational injustices that mediate part of the problem in the first place.

        Recently, many psychosocial researcher-practitioners have touted “community-based participatory research” (CBPR) as an innovative and inclusive methodology for addressing stakeholder equity and engagement in this space; however, I question if this way of relating and working together really fundamentally changes epistemic hierarchies and decision making powers . Is it really a new wine or just a new wine bottle?

See: The only project to date that this writer could find that actually seeks to fully address this

We suspect that in order to sustainably address the limitations endemic to academic research and professional practice, we need to reflect upon and adapt our ways of relating and practicing such that they function to lessen epistemic injustices and power imbalances within and across all interactions so that we can optimize our collective capacities to integrate information and create better solutions.

Bibliography

Han, Paul K. J., William M. P. Klein, and Neeraj K. Arora. 2011. “Varieties of Uncertainty in Health Care: A Conceptual Taxonomy.” Medical Decision Making 31 (6): 828–38. https://doi.org/10.1177/0272989X10393976. Cite
Hazlett, Allan. 2012. “HIGHER-ORDER EPISTEMIC ATTITUDES AND INTELLECTUAL HUMILITY.” Episteme 9 (3): 205–23. https://doi.org/10.1017/epi.2012.11. Cite
Borsboom, Denny, Angélique O. J. Cramer, and Annemarie Kalis. 2019. “Brain Disorders? Not Really: Why Network Structures Block Reductionism in Psychopathology Research.” Behavioral and Brain Sciences 42: e2. https://doi.org/10.1017/S0140525X17002266. Cite
Hyman, Steven E. 2014. “Revitalizing Psychiatric Therapeutics.” Neuropsychopharmacology 39 (1): 220–29. https://doi.org/10.1038/npp.2013.181. Cite
“Identifying the Challenges in Community-Based Participatory Research Collaboration.” 2011. AMA Journal of Ethics 13 (2): 105–8. https://doi.org/10.1001/virtualmentor.2011.13.2.jdsc2-1102. Cite

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Who are You? Who am I? And the Problem of Identity Optics

We desperately act in ways that are less and less driven by our real values, and that are increasingly driven by our need to be valued. Maybe that anxious, phrenetic energy undermines our ability to stop, reflect, and think. Maybe the best way that we can do to functionally manage is to seek refuge in the comfort of categorical simplicity and binaries: of dramatic hero-villain narratives. 

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